avoidance behavior – American ME and CFS Society

Mechanisms of change underlying the efficacy of cognitive behaviour therapy for chronic fatigue syndrome in a specialist clinic: a mediation analysis

Abstract:

BACKGROUND: Several randomized controlled trials (RCTs) have shown that cognitive behavioural psychotherapy (CBT) is an efficacious treatment for chronic fatigue syndrome (CFS). However, little is known about the mechanisms by which the treatment has its effect. The aim of this study was to investigate potential mechanisms of change underlying the efficacy of CBT for CFS. We applied path analysis and introduce novel model comparison approaches to assess a theoretical CBT model that suggests that fearful cognitions will mediate the relationship between avoidance behaviour and illness outcomes (fatigue and social adjustment).

METHOD: Data from 389 patients with CFS who received CBT in a specialist service in the UK were collected at baseline, at discharge from treatment, and at 3-, 6- and 12-month follow-ups. Path analyses were used to assess possible mediating effects. Model selection using information criteria was used to compare support for competing mediational models.

RESULTS: Path analyses were consistent with the hypothesized model in which fear avoidance beliefs at the 3-month follow-up partially mediate the relationship between avoidance behaviour at discharge and fatigue and social adjustment respectively at 6 months.

CONCLUSIONS: The results strengthen the validity of a theoretical model of CBT by confirming the role of cognitive and behavioural factors in CFS.

Source: Stahl D, Rimes KA, Chalder T. Mechanisms of change underlying the efficacy of cognitive behaviour therapy for chronic fatigue syndrome in a specialist clinic: a mediation analysis. Psychol Med. 2014 Apr;44(6):1331-44. doi: 10.1017/S0033291713002006. Epub 2013 Aug 12. https://www.ncbi.nlm.nih.gov/pubmed/23931831

Fear of movement and avoidance behaviour toward physical activity in chronic-fatigue syndrome and fibromyalgia: state of the art and implications for clinical practice

Abstract:

Severe exacerbation of symptoms following physical activity is characteristic for chronic-fatigue syndrome (CFS) and fibromyalgia (FM). These exacerbations make it understandable for people with CFS and FM to develop fear of performing body movement or physical activity and consequently avoidance behaviour toward physical activity. The aims of this article were to review what measures are available for measuring fear of movement and avoidance behaviour, the prevalence fear of movement and avoidance behaviour toward physical activity and the therapeutic options with fear of movement and avoidance behaviour toward physical activity in patients with CFS and FM.

The review revealed that fear of movement and avoidance behaviour toward physical activity is highly prevalent in both the CFS and FM population, and it is related to various clinical characteristics of CFS and FM, including symptom severity and self-reported quality of life and disability. It appears to be crucial for treatment (success) to identify CFS and FM patients displaying fear of movement and avoidance behaviour toward physical activity.

Individually tailored cognitive behavioural therapy plus exercise training, depending on the patient’s classification as avoiding or persisting, appears to be the most promising strategy for treating fear of movement and avoidance behaviour toward physical activity in patients with CFS and FM.

Comment in: Fear of movement and avoidance behaviour toward physical activity in chronic-fatigue syndrome and fibromyalgia: state of the art and implications for clinical practice. [Clin Rheumatol. 2013]

Source: Nijs J, Roussel N, Van Oosterwijck J, De Kooning M, Ickmans K, Struyf F, Meeus M, Lundberg M. Fear of movement and avoidance behaviour toward physical activity in chronic-fatigue syndrome and fibromyalgia: state of the art and implications for clinical practice. Clin Rheumatol. 2013 Aug;32(8):1121-9. doi: 10.1007/s10067-013-2277-4. Epub 2013 May 3. https://www.ncbi.nlm.nih.gov/pubmed/23639990

Coping styles in chronic fatigue syndrome: findings from a population-based study

Chronic fatigue syndrome (CFS) is a common and debilitating illness [1]. As yet the pathophysiology of CFS remains inchoate, so pharmacologic management aims to alleviate symptoms and is not curative. Cognitive-behavioral therapy and graded exercise therapy appear to be the most effective treatments for CFS [2]. Such therapies require that patients understand, adhere to and practice specific activities to manage their thoughts and expenditure of physical energy. This necessary understanding and commitment are heavily impacted by patients’ coping styles and concomitant psychopathology. In a previous population-based study, we found that people with CFS were significantly more likely to use maladaptive everyday coping strategies than non-fatigued matched controls [3]. In another population-based study, we found that about 60% of people with CFS suffered psychiatric comorbidity; in particular affective and anxiety disorders [4], and displayed maladaptive personality styles [5]. In the current population-based study, we examined coping styles in CFS and how these are affected by depression and anxiety.

You can read the rest of this article here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701445/

Source: Nater UM, Maloney E, Lin JM, Heim C, Reeves WC. Coping styles in chronic fatigue syndrome: findings from a population-based study. Psychother Psychosom. 2012;81(2):127-9. doi: 10.1159/000329996. Epub 2012 Feb 2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701445/ (Full article)

Long-term sickness absence among patients with chronic fatigue syndrome

Abstract:

Chronic fatigue syndrome is associated with high levels of occupational disability. Consecutive out-patients at a chronic fatigue syndrome treatment service were studied for associations between occupational status, symptom severity and cognitive and behavioural responses to symptoms. All patients had high symptom levels; however, those on long-term sickness absence had significantly more physical fatigue (β = 0.098, P<0.05) and worse sleep (β = 0.075, P<0.05). Patients with long-term sickness absence also demonstrated more embarrassment avoidance cognitions (β = 0.086, P<0.05) and avoidance resting behavioural responses (β = 0.078, P<0.05). Identifying and addressing avoidance behaviours and cognitions regarding embarrassment in interventions may enhance the chances of individuals returning to work.

Source: Knudsen AK, Henderson M, Harvey SB, Chalder T. Long-term sickness absence among patients with chronic fatigue syndrome. Br J Psychiatry. 2011 Nov;199(5):430-1. doi: 10.1192/bjp.bp.110.082974. Epub 2011 Sep 8. http://bjp.rcpsych.org/content/199/5/430.long (Full article)

Does a decrease in avoidance behavior and focusing on fatigue mediate the effect of cognitive behavior therapy for chronic fatigue syndrome?

Abstract:

OBJECTIVE: Cognitive behavior therapy (CBT) leads to a significant reduction in fatigue severity and impairment in patients with chronic fatigue syndrome (CFS). The purpose of the present study was to determine whether the effect of CBT for CFS on fatigue and impairment is mediated by a decrease in avoidance behavior and focusing on fatigue.

METHODS: For this purpose, we reanalyzed a randomized controlled trial which was previously conducted to test the efficacy of CBT for CFS. Two hundred nineteen patients completed assessment prior and subsequent to treatment or a control group period.

RESULTS: Mediation analysis revealed that a decrease in focusing on fatigue mediated the effect of CBT for CFS on fatigue and impairment. Avoidance of activity and avoidance of aversive stimuli were not significantly changed by treatment and were therefore excluded from mediation analysis.

CONCLUSION: A decrease in the focus on fatigue seems to contribute to the treatment effect of CBT for CFS.

Source: Wiborg JF, Knoop H, Prins JB, Bleijenberg G. Does a decrease in avoidance behavior and focusing on fatigue mediate the effect of cognitive behavior therapy for chronic fatigue syndrome? J Psychosom Res. 2011 Apr;70(4):306-10. doi: 10.1016/j.jpsychores.2010.12.011. Epub 2011 Feb 12. https://www.ncbi.nlm.nih.gov/pubmed/21414449

Coping styles in people with chronic fatigue syndrome identified from the general population of Wichita, KS

Abstract:

OBJECTIVE: Studies of primary and tertiary care patients suggest that maladaptive coping styles contribute to the pathogenesis and maintenance of chronic fatigue syndrome (CFS). We assessed coping styles in persons with unexplained fatigue and nonfatigued controls in a population-based study.

METHODS: We enrolled 43 subjects meeting the 1994 Research Case Definition of CFS, matching them with 61 subjects with chronic unexplained fatigue who did not meet criteria for CFS [we term them insufficient symptoms or fatigue (ISF)] and 60 non-ill (NI) controls. Coping styles and clinical features of CFS were assessed using standard rating scales.

RESULTS: Subjects with CFS and ISF reported significantly more escape-avoiding behavior than NI controls. There were no differences between the CFS and ISF subjects. Among participants with CFS, escape-avoiding behavior was associated with fatigue severity, pain, and disability.

CONCLUSIONS: We demonstrate significantly higher reporting of maladaptive coping in a population-based sample of people with CFS and other unexplained fatiguing illnesses defined by reproducible standardized clinical empirical means in comparison to NI controls.

Source: Nater UM, Wagner D, Solomon L, Jones JF, Unger ER, Papanicolaou DA, Reeves WC, Heim C. Coping styles in people with chronic fatigue syndrome identified from the general population of Wichita, KS. J Psychosom Res. 2006 Jun;60(6):567-73. https://www.ncbi.nlm.nih.gov/pubmed/16731231

Childhood experiences of illness and parenting in adults with chronic fatigue syndrome

Abstract:

OBJECTIVE: There are many similarities between chronic fatigue syndrome (CFS), the somatoform disorders and problems otherwise known as “medically unexplained symptoms.” There is some evidence to suggest that a combination of inadequate parenting and early illness experience may predispose the individual to develop medically unexplained symptoms in adult life. The aim of this investigation was to compare the contributions of childhood experiences of illness and parenting in adults with CFS with a fracture clinic control group.

METHOD: A retrospective case control design was used. Thirty patients with a diagnosis of CFS and 30 patients attending a fracture clinic in an inner London teaching hospital completed questionnaires measuring parental care and protection and were interviewed about childhood experiences of illness.

RESULTS: There were no differences in childhood experience of illness in the two groups. However, logistic regression revealed that maternal overprotection and depression were associated with the diagnosis of CFS.

CONCLUSION: The findings may represent risk factors for the development of CFS in adult life. It is possible that maternal overprotection in particular is related to the formation of belief systems about avoiding activity that operate to adversely influence behaviour in patients with CFS.

Source: Fisher L, Chalder T. Childhood experiences of illness and parenting in adults with chronic fatigue syndrome. J Psychosom Res. 2003 May;54(5):439-43. http://www.ncbi.nlm.nih.gov/pubmed/12726900

Coping strategies in twins with chronic fatigue and chronic fatigue syndrome

Abstract:

OBJECTIVES: Individuals with chronic fatigue and chronic fatigue syndrome (CFS) face debilitating symptoms as well as stressful life situations that may result from their condition. The goal of this study was to examine the coping strategies used by fatigue-discordant twin pairs.

METHODS: We utilized a co-twin design to assess how twin pairs discordant for chronic fatigue and CFS cope with stress. All twin pairs were administered the Revised Ways of Coping Checklist.

RESULTS: Overall, the pattern of coping strategies was similar for fatigued and non-fatigued twins. However, twins with chronic fatigue or CFS utilized more avoidance strategies than their non-fatigued counterparts; those with chronic fatigue also used more avoidance relative to problem-focused coping than their co-twins.

CONCLUSIONS: These results suggest that while fatigue-discordant twins generally exhibit similar behavior patterns in order to cope with stress, there may be an association between fatigue and avoidance coping. Future research should focus on the role of avoidance and its relationship to fatiguing illnesses.

Source: Afari N, Schmaling KB, Herrell R, Hartman S, Goldberg J, Buchwald DS. Coping strategies in twins with chronic fatigue and chronic fatigue syndrome. J Psychosom Res. 2000 Jun;48(6):547-54. http://www.ncbi.nlm.nih.gov/pubmed/11033373

Coping and other predictors of outcome in chronic fatigue syndrome: a 1-year follow-up

Abstract:

In this prospective study, 137 patients with chronic fatigue syndrome were followed-up at a 1-year interval to determine factors relating to outcomes. Nearly two thirds reported an improvement on direct ratings of change.

In analyses with fatigue and functional impairment at follow-up as the criteria, and controlling for earlier status, poorer outcomes were predicted by illness duration, subjective cognitive difficulty, and somatic symptoms; there was no influence of anxiety, depression, or general emotional distress.

Fatigue was also predicted by information-seeking, and impairment by behavioral disengagement and a low internal locus of control. The belief that one’s actions can influence outcomes modified the relationship between illness accommodation and both fatigue and impairment; adverse outcomes were associated with accommodating to illness only in the context of lower levels of perceived control. Thus, it is suggested that interventions that either discourage avoidance of activity or enhance perceived control could benefit the course of the illness.

Source: Ray C, Jefferies S, Weir WR. Coping and other predictors of outcome in chronic fatigue syndrome: a 1-year follow-up. J Psychosom Res. 1997 Oct;43(4):405-15. http://www.ncbi.nlm.nih.gov/pubmed/9330240

Management of chronic (post-viral) fatigue syndrome

Abstract:

Simple rehabilitative strategies are proposed to help patients with the chronic fatigue syndrome. A model is outlined of an acute illness giving way to a chronic fatigue state in which symptoms are perpetuated by a cycle of inactivity, deterioration in exercise tolerance and further symptoms. This is compounded by the depressive illness that is often part of the syndrome. The result is a self-perpetuating cycle of exercise avoidance. Effective treatment depends upon an understanding of the interaction between physical and psychological factors. Cognitive behavioural therapy is suggested. Cognitive therapy helps the patient understand how genuine symptoms arise from the frequent combination of physical inactivity and depression, rather than continuing infection, while a behavioural approach enables the treatment of avoidance behaviour and a gradual return to normal physical activity.

Source: S Wessely, A David, S Butler, and T Chalder. Management of chronic (post-viral) fatigue syndrome. J R Coll Gen Pract. 1989 Jan; 39(318): 26–29. PMCID: PMC1711569 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1711569/ (Full article)